Sara Chapman Definition Progressive narrowing of the pyloric canal Hypertrophied pyloric muscle Occurs in infancy Infantile hypertrophic pyloric stenosis Domino Baldor ID: 590709
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Slide1
Pyloric Stenosis
Sara ChapmanSlide2
Definition
Progressive narrowing of the pyloric canal.
Hypertrophied pyloric muscle.
Occurs in infancy.
Infantile hypertrophic pyloric stenosis.
(Domino
,
Baldor
,
Golding
,
&
Grimes,
2015
). Slide3
pathophysiology
H
ypertrophy
and hyperplasia of the 2
muscular
layers of the
pylorus leads to
narrowing of the gastric
antrum
.
The pyloric canal becomes lengthened, and the whole pylorus becomes thickened.
M
ucosa is edematous
and thickened.
The stomach can become markedly
dilated in response to near-complete
obstruction.
Gastric outflow is obstructed.
(Singh &
Sinert
,
n.d.
).
Gastric distention and vomiting.
(Domino,
Baldor
, Golding, & Grimes, 2015). Slide4
Pathophysiology
Image retrieved from https://www.google.com/search?q=pyloric+stenosis+pathophysiologySlide5
etiology
Exact cause is unknown.
Use of Fluoxetine in the 1
st
trimester of pregnancy?
Genetics?
(
Domino,
Baldor
, Golding, & Grimes, 2015, p. 1014). Slide6
Incidence & Risk Factors
3/1000 live
births.
4x increase in males
vs
females.
Familial.
Most common in
Caucasian
first-born
males.
(Domino, Baldor, Golding, & Grimes, 2015, p. 1014). (Burns, Dunn, Brady, Starr, & Blosser, 2013, p. 980).Slide7
Screening
Not routine.
Screen if clinical findings consistent with pyloric stenosis…. (Next slide!)Slide8
Clinical findings
History
Typical onset is at 3-6 weeks of age.
Projectile vomiting after feeding (non-bilious).
Vomiting increasing in frequency and severity.
Blood tinged emesis.
Hunger.
Weight loss.
Decrease in bowel movements.
(
Domino,
Baldor
, Golding, & Grimes, 2015, p. 1014).
Image retrieved
fwww.google.com/search?q=pyloric+stenosis+pathophysiologyrom https://Slide9
Clinical findings
physical exam
Early signs:
Firm, mobile, “olive-like” mass palpable in the middle upper or RUQ.
Epigastric
distention.
Visible gastric peristalsis after feeding.
Late signs:
Dehydration.
Jaundice when inadequate nutrition leads to indirect
hyperbilirubinemia
(rare).
(Domino, Baldor, Golding, & Grimes, 2015, p. 1014).
referred Slide10
Olive like mass
Images retrieved from https://www.google.com/search?q=pyloric+stenosis+olive+signSlide11
Differential diagnosis
Inexperienced or inappropriate feeding.
Gastroesophageal
reflux disease.
Gastritis.
Congenital adrenal hyperplasia.
Pylorospasm
.
Gastric volvulus.
Antral
or gastric web. (
Domino,
Baldor, Golding, & Grimes, 2015, p. 1014) (Congenital adrenal hyperplasia,
n.d.) (Hope, 2013) (Bell, Ternberg, Keating, Moedjona, McAlister, & Shackelford, 1978). Slide12
considerations
Prompt treatment to avoid dehydration and malnutrition.
IV fluids to correct dehydration and metabolic abnormalities.
Apnea monitoring.
(
Domino,
Baldor
, Golding, & Grimes, 2015, p. 1014)Slide13
Laboratory tests/diagnostics
Check electrolytes
CMP
Bili
Abdominal US is the study of choice
Thickened and elongated pyloric muscle
Upper GI series
Strong gastric contractions (
Domino,
Baldor
, Golding, & Grimes, 2015, p. 1014)Slide14
Management/treatment
non-pharmacologic
Surgery
Ramstedt
pyloromyotomy
– the entire length of the hypertrophied muscle is divided. The underlying mucosa is preserved.
Can be done open, laparoscopic, or by a contemporary
circumbilical
incision.
(
Domino,
Baldor, Golding, & Grimes, 2015, p. 1014)Slide15
Management/treatment
Pharmacologic
Atropine
Lower success rate and longer duration than surgery.
Surgical alternative for patients unsuitable or at high risk for surgery.
(Domino,
Baldor
, Golding, & Grimes, 2015, p. 1014)Slide16
cOMPLICATIONS
No long term morbidity.
Duodenal perforation.
No major difference between open vs. lap.
pyloromyotomy
, although laparoscopic approach has faster time back to full feeding & shorter hospital stay.
(Domino,
Baldor
, Golding, & Grimes, 2015, p. 1014)Slide17
Follow up
Postoperative monitoring including monitoring for pain, apnea, and emesis.
Routine pediatric health maintenance thereafter.
(Domino,
Baldor
, Golding, & Grimes, 2015, p. 1014)Slide18
Counseling/education
Vomiting may continue for a few days after surgery.
Not as significant as pre-op.
Vomiting which continues more than 5 days after surgery should be investigated.
Introduce feedings gradually.
Prognosis after surgery is excellent.
(Burns, Dunn, Brady, Starr, &
Blosser
, 2013, p. 980
)Slide19
Consultation/referral
Pediatric Gastroenterologist.
Pediatric Surgeon.Slide20
Question #1
Pyloric
Stenonosis
is most commonly seen in?
A) Females
B) MalesSlide21
Answer #1
B) Males
Rationale:
There are four times the number of male babies born with the condition as opposed to females. Slide22
Question #2
Clinical finding consistent with pyloric stenosis include:
A)
B
ilious project vomiting
B) Non-bilious projectile vomiting
C) Weight gain
D) Increase in bowel movementsSlide23
Answer #2
B) Non-bilious projectile vomiting.
Rationale: Gastric outflow is obstructed, which leads to gastric distention and vomiting, so babies are vomiting feedings soon after taking it in. Clinical findings also include weight loss and a decrease in bowel movements.Slide24
Question #3
True or false: Pyloric stenosis is familial.
A) True
B) FalseSlide25
Answer #3
A) True
Rationale: The
condition tends to be familial. There is a 5x increased risk with an affected 1
st
degree relative Slide26
Question #4
What is the study of choice used to diagnose pyloric stenosis?
A) CT abdomen
B) Upper GI series
C) Abdominal US
D) MRI abdomenSlide27
Answer #4
C) Abdominal US
Rationale: Abdominal US is the study of choice to diagnose pyloric stenosis. Pyloric stenosis will show thickened and elongated pyloric muscle.Slide28
Question #5
Which group is pyloric stenosis seen in most commonly?
A) Hispanic 1
st
born females
B) Hispanic 1
st
born males
C) Caucasian 1
st
born females
D) Caucasian 1
st born malesSlide29
Answer #5
D) Caucasian 1
st
born malesSlide30
Question #6
What is a late sign of pyloric stenosis?
A) Dehydration
B) “Olive-like” mass in middle upper or RUQ
C)
Epigastric
distention
D) Visible peristalsis after feedingSlide31
Answer #6
A) Dehydration
Rationale: Pyloric stenosis that goes undiagnosed for some time can result in dehydration. Olive sign,
epigastric
distention, and visible gastric peristalsis after feeding are the first presentations of pyloric stenosis.Slide32
Question #7
True or false: Dehydration may cause metabolic abnormalities with pyloric stenosis.
A) True
B) FalseSlide33
Answer #7
A) True
Rationale: Frequent vomiting seen with pyloric stenosis may lead to dehydration, which can lead to metabolic abnormalities.Slide34
Question #8
Name a pharmacologic intervention appropriate for treatment of pyloric stenosis.
A) Zantac
B) Omeprazole
C) Atropine
D)
Amlodapine
Slide35
Answer #8
C) Atropine
Rationale: Although it has a lower success rate and longer duration of treatment, for patients who surgery is contraindicated or are high risk, Atropine may be used.Slide36
Question #9
True or false: Babies with pyloric stenosis may have blood tinged emesis.
A) True
B) FalseSlide37
Answer #9
A) True
Rationale: Gastric irritation from frequent vomiting causes blood tinged emesis.Slide38
Question #10
When does pyloric stenosis typically first present?
A) 9 months
B) At birth
C) 6 months
D) 3-6 weeksSlide39
Answer #10
D) 3-6 weeks
Rationale: Pyloric stenosis typically first presents at age 3-6 weeks. It rarely occurs in the newborn period or after 5 months of age.Slide40
references
Burns, C., Dunn, A., Brady, M., Starr, N., &
Blosser
, C. (2013).
Pediatric primary care
(5th ed
., p. 980).
Philadelphia, PA: Elsevier.
Domino,
F.,
Baldor
, R., Golding, J., & Grimes, J.
(2015). The 5-minute clinical consult standard 2015 (23rd ed., p. 1014-1015). Philadelphia, PA: Wolters Kluwer Health.Singh, J., & Sinert, R. (
n.d.). Pediatric Pyloric Stenosis . Retrieved September 29, 2014, from http://emedicine.medscape.com/article/803489-overview#a0104Congenital adrenal hyperplasia. (n.d.). Retrieved September 29, 2014.Hope, W. (2013, March 4). Gastric Volvulus . Retrieved September 29, 2014.
Bell, M., Ternberg, J., Keating, J., Moedjona, S., McAlister, W., & Shackelford, D. (1978, June 13). Prepyloric gastric entral web: a puzzling epidemic. Retrieved September 29, 2014.